Using Quality Improvement to Lower Cesarean Rates

Kathleen DeMarco, MSN, NE-BC, CPHQ, RN, the Senior Director of Nursing at New York University (NYU) Langone Health. About five years ago, she began working to build capacity for quality improvement (QI). DeMarco started meeting with the Department of Obstetrics’ Quality Committee (QC), which is composed of about eight physicians from different backgrounds. “We adopted the Joint Commission definitions for severe maternal morbidity and mortality, and that’s what we based our program on," said DeMarco.

Three years ago, the QC decided they wanted to be more transparent with the data they collected. Since then, the QC has sent out a monthly departmental scorecard with basic statistics, including the number of births, number of multiple births, number of mothers admitted to the ICU, cesarean birth rate, and forceps rate.

“Every member of the team is able to see our data,” explained DeMarco. The scorecard is shared with nursing staff, physicians, anesthesiologists, patient unit associates, and scrub technicians.

Monitoring has played a vital role in QI efforts within the Department of Obstetrics. “Since we’re looking at the data all the time, we are able to see shifts in our data, like climbing rates of C-sections, climbing rates of episiotomy. And then we try to make a considerable effort to trend our data and look for opportunities for improvement.”

The first project that the Department of Obstetrics conducted using complete transparency was reducing their episiotomy rate. The QC provided each physician with a score card of their own rate and the desired ACOG benchmark. Then, they asked providers to verbally consent each patient. They offered opportunities for mentoring and education. With time, they were able to track falling rates of episiotomies. Finally, they congratulated the physicians.

NYU Langone's QC is currently working to reduce their cesarean birth rate and “[e]ven just moving from 27 to 29.9 percent in the last month made us feel a little bit uncomfortable,” said DeMarco.

When the QC met to discuss cesarean rates, she was prepared to share hospital data, best practice from relevant governing bodies, and materials from the California Maternal Quality Care Collaborative. They agreed to conduct a QI project to reduce cesarean rates, beginning with adopting CMQCC's scorecard methodology.

Six weeks ago, they sent each provider a blinded scorecard containing every provider’s cesarean rate and a unique identifier so providers could determine their rate.

“We included on the scorecard the number of cesarean sections they would need to avoid in order to lower their rate to the Leapfrog rate, which is 23.9 percent.” Many physicians need to avoid one cesarean birth a month to lower their rate to the target, which is also the Healthy People 2020 target for low risk births to first time moms, or NTSV cesarean rate.

To support providers in lowering their rates, the QC is offering mentoring, education, and access to patient level data. In addition, providers have been given what DeMarco described as a definitions table of ACOG supported definitions for indication for a delivery via C-section. They plan to send out another blinded scorecard at three months, and an unblinded scorecard at six months.

Kathleen DeMarco's advice for people who are considering engaging in QI:

"People respond well to well-planned interventions.”

“Get help. If you are not sure how to do this work, find a leader in the field. I’m sure they’ll give you their time.”

“There are a lot of online resources. You can learn a lot from getting the proper education.”

“You need to be organized. You need to know…

What are you trying to accomplish?

What information do you have or do you not have that would inform the problem?

Who are your key champions or stakeholders on the topic?”

“Gather that group together and talk through your problem, your data, and the data you need to find.”

“Before you start implementing anything… Know what your strategy is going to be, who your audience is, and why you are doing it. It’s easier for people to join you if you are prepared to tell your story.”